Culligan, Charles Farm vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
`ar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.�:.... :_......._.. ...._
Village
Dist. No. ..C:l..County.... or City �,/ -,�; %'u
�'� /r (If city,give street address).
Name of deceased RrG�e - G�c4 Veteran lli-,7-1 `��-r'.Z
wd.... ,,�r Yj
Single, married, widowed, / !/ < ,� (If veteran, siv name of War)
Sex.... ..Color or divorced (write the word)... .'m om- Date of Deathea l / e p C,/
S Age 6 Years Months Days _ Birthplace f.
Cause of Death... - 1r, ,,�
Certificate was signed by ..a '...., ... cz�./ M.D.
Address kz2:c 7 .,, , o "77 ".-
Place of Burial (or Removal). ... C Tj 7 .,4.c„!, ,, z
. .J/ (/ J�
- Cj
�C., ` 'j
(If body is to be tem r;rily helde,,;Il p later)
Cemetery ' f-= 'L c2 Clu j. Date of Burial 19:/..
(If body is to be temporarily held,b in space later) /
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number,ifilltd on the basis7tthereof ) HER Y GRANT A PERMIT(age)--/ C/ (Address)
the �..,�.f `' to hold temporarily and... the body.
(Undertaker or pe haring charge of corpse) (Inter,remo ,or otherwise dig*of a Mate how])
Dated 1 ..../•....$ 19 (Signed)
b Local Registrar
This Permit is su cient for the Removal (and Interment or Cremation) of body to any part of the Starts (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX`1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of v was ` 19__(Interment or Cremation) /14/
(Name of Cemetery, Crematorium, etc.)
Section Lot No. .-. Grave No.
(Signed)
(Pinon n charge)
Address
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.